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| "ProvenCareSM": A Provider Driven Pay For Performance Program for Acute Episodic Cardiac Surgical Care | Alfred S Casale*, Albert Bothe, Jr.*, Ronald Paulus*, Mark Selna*, Karen McKinley*, Michael C Doll*, Scott A. Berry*, Glenn D Steele
Geisinger Health System, Danville, PA
| OBJECTIVE(S): To-date, "Pay-for-Performance” (P4P) strategies have addressed increasing costs, use of best-practices, and provider reimbursement incentives that pay for suboptimal outcomes, and are usually insurer-imposed and focused on primary care. Using an integrated system of clinicians, hospitals and an insurance plan, all connected by an electronic health record (EHR), we implemented a provider-driven P4P model for patients undergoing elective coronary artery bypass grafting.
METHODS: Cardiovascular surgeons reviewed each of the Class I and IIa "2004 ACC/AHA Guidelines for CABG Surgery" and translated them into 45 verifiable processes. These best-practices were imbedded within a new ProvenCareSM process and “hardwired” within the EHR, orders, and “time out” procedures. All care (pre-op, in-patient and post-op), including treatment of complications within 90 days as well as rehabilitation, was packaged into a single fixed price. All elective CABG patients treated between 2/1/06 and 10/31/06 were included and compared to 143 patients treated conventionally in 2005.
RESULTS: Initially, only 60% of patients had all ProvenCareSM elements met. At three months compliance with ProvenCareSM was 100% and remained above 90% through 11/06. Thirty-day outcomes improved (Table 1), with reduction in combined complications approaching statistical significance even at this early stage of the program. Mean hospital charges fell 5.2%; length of stay decreased 12%.
CONCLUSION: A provider-driven P4P process for CABG can reliably deliver evidence-based ProvenCareSM that improves outcomes while lowering costs.
| | ProvenCare Group
n = 81 | % | Conventional Care Group 2005
n = 143 | % | p Value | Statistical Test | | Total complications | 27 | N/A | 82 | N/A | 0.06 | Wilcoxon's rank sum | | Discharged home | 75 | 92.6 | 116 | 81.1 | 0.02 | Chi-square | | Patients with any complication | 24 | 29.6 | 54 | 37.8 | 0.22 | Chi-square | | Patients receiving blood products | 15 | 18.5 | 36 | 25.2 | 0.26 | Chi-square | | Readmitted to ICU | 0 | 0 | 4 | 2.8 | 0.30 | Fisher's exact | | Pulmonary complications | 2 | 2.5 | 9 | 6.3 | 0.33 | Fisher's exact | | Operative mortality | 0 | 0 | 2 | 1.4 | 0.53 | Fisher's exact | | Atrial fibrillation | 15 | 18.5 | 31 | 21.7 | 0.58 | Chi-square | | Deep sternal wound infection | 0 | 0 | 1 | 0.7 | 1.00 | Fisher's exact |
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